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i've been an adn for 16 years. recently, i finished my bsn and now am through my first year of a dnp program. like most students, i struggled with learning to understand a nursing diagnosis during my adn schooling. since that time the term has cropped up in various situations but usually as a passing comment. it has in no way benefitted my practice as a nurse. in fact, when i bring up the subject with colleagues i often get a smirk or an eye-roll!
the subject of nursing diagnoses happened to come up in one of my grad school classes the other day. i decided to take a stab at this sacred cow and suggest that maybe they are burdensome and irrelevant to a working nurse that they simply aren't utilized. my professor's response was a textbook explanation that i've only heard repeated on a college campus. "if you say your patient has pneumonia, you are using a medical diagnosis which is outside your scope of nursing practice. you must have a nursing diagnosis to be able to implement and evaluate your interventions." i may be wrong, but i'm pretty sure i've been able to implement and evaluate my nursing interventions without needing a nursing diagnosis.
personally, i believe the idea for a nursing diagnosis comes from the ongoing and hard-won independence from the thumb of the medical community. i am all for the continued growth of nursing science. however, on this point we overshot the mark. there is simply no justifiable rationale for calling pneumonia something like
"impaired gas exchange related to effects of alveolar-capillary membrane changes. or
ineffective airway clearance related to effects of infection, excessive tracheobronchial secretions, fatigue and decreased energy, chest discomfort and muscle weakness. "
why not just say the patient has pneumonia? because it a medical diagnosis and we don't practice medicine? baloney! its a pathologic condition. call it what it is. we dont need to reinvent the wheel.
why do we hang on to this? we need to eject it from nursing and maybe realize we don't use it like we thought we would. a lot of time and energy is wasted on this topic in nursing programs that could be better spent elsewhere.
what say you?
Care plans are one thing, and Nursing DX is another. I like care plans, more directly care maps, but Nursing DX is junk. Yes, we care for people, but people have diseases. Don't drink the kool-aid of Nursing DX. As for billing, the whole system needs to be overhauled.
OP
What do you suggest we change to? If we simply follow medical diagnosis, how can we be regarded as anything but a physician's handmaiden? I think you are correct in that there needs to be a change in some of the ND, but the nursing diagnosis are very helpful to us educators who have to show the difference between nursing and medicine. The root of the problem is that you cannot charge for ND the way you can for a medical diagnosis.
Thank you for an eloquent explanation of the problem. When I was in nursing school I just couldn't believe the concept of nursing diagnoses. Even as I wrote my care plans, I always said to myself stuff like "but it's really shock" or "but the patient's actually dehydrated" or "this guy's hypoxic because he's got pneumonia" etc. I learned to write the same things in politically correct nurse-talk though.
Even though our teachers used to keep talking about it, I've never understood the need to differentiate ourselves from the medical model and I've never worried about being a "handmaiden" of the physicians or being under their thumb. Instead I view myself as part of a team where the MDs identify the basic problem and direction of treatment and we fill in and elaborate on the treatment to fill the patient's needs. The good physicians work with us as part of the team and the stupid physicians act like prima donnas and ruin the efficiency of their teams.
I'm not even going to pretend like I use nursing diagnoses in my practice, because I don't. I haven't even thought about them since school, to be honest. I also definitely think that when you look at the lists in books, they can get into the realm of the stupid sometimes.
However, I actually do think they are useful to students (even though I feel like I'm going to be hit by some tomatoes for saying so.) I think they are helpful in teaching the student how to think like a nurse. If your diagnosis is pneumonia, the only way you can really fix that is through medical intervention, and the nurse does the very important job of implementing the medical treatment plan. However, if the problems are stated as impaired gas exchange or ineffective airway clearance or anxiety or whatever, it requires the student to think: What can I do as a nurse to fix this problem? It encourages the student to produce independent nursing actions.
The nursing diagnosis states the problem, or the thing that nurse is going to address, rather than just stating the patho. If a patient is diagnosed with stomach cancer, what is actually going on with her? We may know the patho, but what is bothering her exactly? There can be lots of problems, or nursing diagnoses, for something like that, and lots of nursing interventions for those problems.
Of course, I think we eventually move beyond the need to express these problems in the form of the nursing diagnosis, and we identify problems without even realizing we are doing it. However, I think the nursing diagnosis gives students a head start on that process.
"What do you suggest we change to? If we simply follow medical diagnosis, how can we be regarded as anything but a physician's handmaiden?"
I suggest we don't change to anything. In healthcare, all disciplines must speak the same language, especially in the growing interdisciplnary team approach. There is nothing holding us back from having "dual intervention" tracks that include nursing and medical interventions. Other disciplines (physical, speech, and occupational therapies, pharmacy, Rt, etc) have grown and developed their respective specialties without the need for some wacky terminology to set them apart. That being said, nursing works more closely in tandem with medicine than the other disciplines so there is a blurring of where one picks up and the other leaves off. I believe this is why nursing has had a difficult history of defining itself and receiving recognition. However, if challenged to prove my value as a billable service, I certainly would not call attention to a ND. I'm actually embarassed for nursing that we came up with this goofy lingo.
It's funny that nursing informatics was mentioned, as this is the class I'm taking now where the subject came up. I understand the need to show we can generate revenue for a facility through application of nursing science, and not simply be written off as a labor expense.
I can't speak to nursing in LTC as I have very limited experience in that arena. I do see value in the care plan. As you mentioned, it does give a consistent plan for a patient when multiple nurses are providing that care.
"Nursing dx = the Emperor's new clothes"EXACTLY! If nursing is clammering for respect and credibility we deserve and have worked hard for, we have to the objectivity and courage to jettison ideas that just didn't pan out the way we thought they would.
99% agree... and here goes that 1%
(the following is not based on description or summary of any real patient - for HIPPAA's sake):
There is a middle-aged female patient with h/o chronic migraines and chronic low back pain. Physician's Dx in ER: low abdominal pain. Tests' results ruled out surgical pathology, so she is under observation and treated for mild dehydration (medical dx#1), constipation (medical dx#2) and chronic pain (medical dx#3). Home meds to be continued while on floor: oxyContin for back pain and vicodin PRN. She is unemployed, poor, uneducated, has no primary care doctor and only comes to ER to get her "pain pills" every couple of weeks or so. She is cooperative, not very complaining but somewhat anxious and concerned about her own health and her ability to support her 5 small children.
There is a sad medical joke saying: "being stupid or poor isn't a diagnosis yet". There is really no useful medical diagnosis to describe what's going on with this patient as a whole person ("major depression" might be the closest thing to use, but it may very well not be the correct one). I can imagine that most probably the patient will be prescribed "some" Xanax to "control her anxiety", more of her "pain pills" and something for constipation, told to drink more water and eat more fruits and veggies. Therefore, each of her single medical problems will be properly "addressed" and she is discharged to whence she came from. It is very difficult for a doctor even to address her obviously forming dependency on opioids, b/o she truly has that head and back pains and therefore can be sent to pain clinic consult but hardly anywhere else.
Why such a patient cannot "officially" be given diagnosis of "health maintenance, ineffective, r/t lack of material resources, ineffective individual coping, etc"? At least, that would give a picture of an individual unable to manage her own health issues, and in need of much more help than giving her another prescription. Yes, it is a "nursing diagnosis" according to NANDA, but if it encompasses problems crying to be addressed and vitally important for the health of this patient, does it really matter? :redbeathe:redbeathe:redbeathe
Sorry for the long rant...
"What do you suggest we change to? If we simply follow medical diagnosis, how can we be regarded as anything but a physician's handmaiden?"I suggest we don't change to anything. In healthcare, all disciplines must speak the same language, especially in the growing interdisciplnary team approach. There is nothing holding us back from having "dual intervention" tracks that include nursing and medical interventions. Other disciplines (physical, speech, and occupational therapies, pharmacy, Rt, etc) have grown and developed their respective specialties without the need for some wacky terminology to set them apart. That being said, nursing works more closely in tandem with medicine than the other disciplines so there is a blurring of where one picks up and the other leaves off. I believe this is why nursing has had a difficult history of defining itself and receiving recognition. However, if challenged to prove my value as a billable service, I certainly would not call attention to a ND. I'm actually embarassed for nursing that we came up with this goofy lingo.
It's funny that nursing informatics was mentioned, as this is the class I'm taking now where the subject came up. I understand the need to show we can generate revenue for a facility through application of nursing science, and not simply be written off as a labor expense.
I can't speak to nursing in LTC as I have very limited experience in that arena. I do see value in the care plan. As you mentioned, it does give a consistent plan for a patient when multiple nurses are providing that care.
"Nursing dx = the Emperor's new clothes"EXACTLY! If nursing is clammering for respect and credibility we deserve and have worked hard for, we have to the objectivity and courage to jettison ideas that just didn't pan out the way we thought they would.
To you, how do you define nursing? What is the difference between nursing and medicine?
Are we simply Doctor assistants or a stand alone profession with unique goals and interventions?
NANDA was in part developed to unify the nursing language, there are 12 OFFICIAL nursing languages, not including the hundreds of non-approved subset languages. NANDA was ment to unify nursing and all the non-medicine health fields.
The reason why those other specialties do not have their own weird language is becuase they all fall under the nurse's care plan. Every single one of those specialties you pointed out (except the Pharms who are in fact a part of the MD group) are sub-sets and off-shoots of nursing. Every one of those specialties derived from nursing and provide a specialized form of nursing care and in fact fall under the nurse's authority and must abide by the NANDA care plan.
NANDA nursing diagnoses are not only of no value to Nursing education and practice, they are actually quite harmful.
Patricia Benner, arguably the foremost Nursing Educator today, has a new book out which is essentially a 200 page smack-down of Nursing Diagnoses.
Your teacher was ignorant in saying "you are using a medical diagnosis which is outside your scope of nursing practice." My state's Nurse Practice Act states specifically that RN's must be able to utilize Medical Diagnoses in practice.
NANDA nursing diagnoses are not only of no value to Nursing education and practice, they are actually quite harmful.Patricia Benner, arguably the foremost Nursing Educator today, has a new book out which is essentially a 200 page smack-down of Nursing Diagnoses.
Your teacher was ignorant in saying "you are using a medical diagnosis which is outside your scope of nursing practice." My state's Nurse Practice Act states specifically that RN's must be able to utilize Medical Diagnoses in practice.
Did she mention how she would resolve the problem of differentiating nursing from medicine, how to articulate nursing tasks in a billable manner, unify the nursing language, or guide interventions?
Can't just say "she said it was bad" without endulging us with her resolutions. If not NANDA then what?
BTW Benner, although an esteemed theorist, is slightly controversial and while a leading educator is certainly not the foremost...giving a little too much credit me thinks.
To you, how do you define nursing? What is the difference between nursing and medicine?Are we simply Doctor assistants or a stand alone profession with unique goals and interventions?
NANDA was in part developed to unify the nursing language, there are 12 OFFICIAL nursing languages, not including the hundreds of non-approved subset languages. NANDA was ment to unify nursing and all the non-medicine health fields.
The reason why those other specialties do not have their own weird language is becuase they all fall under the nurse's care plan. Every single one of those specialties you pointed out (except the Pharms who are in fact a part of the MD group) are sub-sets and off-shoots of nursing. Every one of those specialties derived from nursing and provide a specialized form of nursing care and in fact fall under the nurse's authority and must abide by the NANDA care plan.
Wow. That's interesting. Perhaps, historically, nursing had performed say physical therapy functions. However, I can assure you that they would reject the idea that they fall under our authority or for that matter even know what a NANDA care plan is. Yeah, sorry, I can't swallow that one. Each of those specialties have their own governing boards/licensure and practice with more autonomy than we do.
Nursing is a stand alone profession. We are developing our own body of science with our own research. We are beginning to prove our economic value to healthcare too. As you know, Medicare will no longer pay for hospital acquired infections. At our hospital, nursing led an initiative to dramatically reduce catheter-acquired UTIs by 40% with only nursing interventions--no doctor orders. This means saving DRG money for the hospital.
orthonurse55
1 Article; 173 Posts
They are still used in LTC and in Home Health. As an instructor, I was just having this same discussion with my class today. When I went to school and started nursing, there was no such thing as a nursing diagnosis. When I started a job in 2001 that used them I was lost for a long tim, trying to figure out why the heck we were doing it. Well, it's partly for reimbursement. And for being able to treat the patient in a holistic manner. The nursing diagnoses is supposed to cover the WHOLE patient, just as our care does. In the "olden days" we all went to work and did our best nursing care based on the doctor's diagnosis for that patient. But we were leaving out some imporatant areas of need. Plus that - your idea of best nursing care may have been different than the nurse on the next shift. So there was no continuity.
In the LTCF's, Te care plan is the "Bible" for the care of the residents. But I do agree that we should be able to tone down those nursing diagnoses somewhat - sometimes it's like grasping at straws to find things to use!